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A Successful Management Of Sever Gummy Smile Using Gingivectomy And Botulinum Toxin Injection: A Case Report

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Introduction: A gummy smile (GS) affects the esthetic and the psychological status as it usually decreases the self-confidence leading to hidden or controlling the smile. A smile with more than 2 mm exposed gingiva is called gummy smile. It may be due to one or more of the following etiologies; altered passive eruption of teeth, dentoalveolar extrusion, vertical maxillary excess, and short or hyperactive lip muscles. The treatment of gummy smile should be planned according to its cause/causes. The purpose of this case report was to highlight the ability of combined treatment of gingivectomy and Botox injection technique in managing a severe gummy smile. Also, techniques, advantages, disadvantages, indication and contraindications of Botulinum toxin (BT) are discussed at the literacy. Presentation of the case: A 24 year old female patient with a severe gummy smile was refereed to the periodontal clinics of our institution. Clinical examination revealed that she has a GS of an 11-12 mm gingival exposed area that was indicated for orthognathic surgery. The GS was treated by a gingivectomy surgery to increase the clinical crowns of upper anterior teeth and the use of Botox injections. The treatment showed remarkable and satisfactory results instead of doing extensive surgery. Discussion and conclusion: It is important to assess the patients' esthetic expectations and show the possible therapeutic solutions that fit him. We revealed that BT is considered as one of the minimally invasive, quick and affordable modalities that can replace extensive surgical procedures for corrections of sever GS.
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CASE
REPORT
OPEN
ACCESS
International
Journal
of
Surgery
Case
Reports
42
(2018)
169–174
Contents
lists
available
at
ScienceDirect
International
Journal
of
Surgery
Case
Reports
journa
l
h
omepage:
www.casereports.com
A
successful
management
of
sever
gummy
smile
using
gingivectomy
and
botulinum
toxin
injection:
A
case
report
Diana
Mostafaa,b,
aPeriodontology
and
Oral
Medicine
Department,
Alexandria
University,
Faculty
of
Dentistry,
Egypt
bPreventive
Dental
Sciences,
Al-Farabi
College,
Riyadh,
Saudi
Arabia
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
1
November
2017
Received
in
revised
form
26
November
2017
Accepted
28
November
2017
Available
online
1
December
2017
Keywords:
Excessive
gingival
display
Gummy
smile
treatment
Botulinum
toxin
injection
Botox
Gingivectomy
a
b
s
t
r
a
c
t
INTRODUCTION:
A
gummy
smile
(GS)
affects
the
esthetic
and
the
psychological
status
as
it
usually
decreases
the
self-confidence
leading
to
hidden
or
controlling
the
smile.
A
smile
with
more
than
2
mm
exposed
gingiva
is
called
gummy
smile.
It
may
be
due
to
one
or
more
of
the
following
etiologies;
altered
passive
eruption
of
teeth,
dentoalveolar
extrusion,
vertical
maxillary
excess,
and
short
or
hyperactive
lip
muscles.
The
treatment
of
gummy
smile
should
be
planned
according
to
its
cause/causes.
The
purpose
of
this
case
report
was
to
highlight
the
ability
of
combined
treatment
of
gingivectomy
and
Botox
injection
technique
in
managing
a
severe
gummy
smile.
Also,
techniques,
advantages,
disadvantages,
indication
and
contraindications
of
Botulinum
toxin
(BT)
are
discussed
at
the
literacy.
PRESENTATION
OF
THE
CASE:
A
24
year
old
female
patient
with
a
severe
gummy
smile
was
refereed
to
the
periodontal
clinics
of
our
institution.
Clinical
examination
revealed
that
she
has
a
GS
of
an
11–12
mm
gingival
exposed
area
that
was
indicated
for
orthognathic
surgery.
The
GS
was
treated
by
a
gingivec-
tomy
surgery
to
increase
the
clinical
crowns
of
upper
anterior
teeth
and
the
use
of
Botox
injections.
The
treatment
showed
remarkable
and
satisfactory
results
instead
of
doing
extensive
surgery.
DISCUSSION
AND
CONCLUSION:
It
is
important
to
assess
the
patients’
esthetic
expectations
and
show
the
possible
therapeutic
solutions
that
fit
him.
We
revealed
that
BT
is
considered
as
one
of
the
minimally
invasive,
quick
and
affordable
modalities
that
can
replace
extensive
surgical
procedures
for
corrections
of
sever
GS.
©
2017
Published
by
Elsevier
Ltd
on
behalf
of
IJS
Publishing
Group
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1.
Introduction
As
facial
esthetic
awareness
of
society
increases,
the
demands
of
dental
esthetics
become
more
than
before
to
meet
the
patients’
expectations.
The
shape,
the
position,
and
the
color
of
teeth
with
the
gingival
tissues
determine
the
harmony
of
a
smile.
Nowadays,
both
patients
and
dentists
are
more
conscious
of
the
impact
of
the
gingiva
on
the
beauty
of
the
smile,
particularly
the
periodontist
who
can
contribute
greatly
to
fix
patients’
smiles
[1].
Moreover,
recent
studies
have
revealed
that
the
amount
of
gingival
display
of
smiling
affects
the
smile
attractiveness
[2,3].
Although
display-
ing
a
certain
amount
of
gingiva
is
esthetically
acceptable
and
in
many
cases
imparts
a
youthful
appearance
[4],
a
smile
with
more
than
2
mm
exposed
gingiva
is
known
to
be
gummy
smile
(GS).
It
is
one
of
the
most
common
alterations
among
the
population,
with
prevalence
10.5%–29%
in
which
females
predominate
[5,6].
The
various
causes
of
GS
include
altered
passive
eruption
of
teeth,
dentoalveolar
extrusion,
vertical
maxillary
excess,
short
or
hyperactive
upper
lip
muscles
(levator
labii
superioris,
levator
labii
Correspondence
to:
Periodontology
and
Oral
Medicine
Department,
Alexandria
University,
Faculty
of
Dentistry,
Egypt.
E-mail
address:
dr.dianamostafa@gmail.com
superioris
alaquae
nasii,
levator
anguli
oris,
and
the
zygomaticus
muscles),
or
combinations
of
them
[7,8].
Accordingly,
to
get
GS
accurate
diagnosis
and
proper
treatment,
dentists
should
recognize
its
main
cause\s.
The
clinical
diagnosis
of
GS
should
include
the
determination
of
clinical
crown
length
(gingival
margin
to
incisal
edge),
anatomic
crown
length
(cementoenamel
junction
to
incisal
edge),
probing
depth
(gingival
margin
to
the
base
of
gingival
sulcus),
width
of
ker-
atinized
gingiva
(free
gingival
margin
to
mucogingival
junction),
frenal
attachment,
overjet
and
overbite
space
of
teeth,
and
the
ver-
tical
limits
of
the
smile.
Besides,
radiographic
examination
should
be
done
to
determine
bone
level,
any
protrusion
of
maxilla
and
excessive
vertical
maxilla.
Treatment
of
GS
by
esthetic
crown
lengthening
with
or
with-
out
osseous
resection
is
well
documented.
It
is
done
to
increase
extension
of
the
clinical
crown
to
restore
the
normal
dentogingival
relationships,
aiming
improvement
of
the
functional
and
esthetic
aspects
[9,10].
It
remodels
the
attachment
apparatus,
eliminates
the
excessive
exposure
of
gingiva,
and
shows
the
correct
dimen-
sions
of
teeth
[11].
The
procedure
involves
two
types
of
surgeries,
which
are
gingivectomy,
and
osseous
surgery,
depending
on
the
amount
of
biological
width
available
in
the
patient.
In
more
illus-
tration,
if
there
are
appropriate
osseous
levels,
more
than
3
mm
https://doi.org/10.1016/j.ijscr.2017.11.055
2210-2612/©
2017
Published
by
Elsevier
Ltd
on
behalf
of
IJS
Publishing
Group
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.
org/licenses/by-nc-nd/4.0/).
CASE
REPORT
OPEN
ACCESS
170
D.
Mostafa
/
International
Journal
of
Surgery
Case
Reports
42
(2018)
169–174
of
gingival
tissues
(from
bone
to
gingival
crest)
and
the
adequate
zone
of
attached
gingiva,
gingivectomy
could
be
done
with
beveled
incisions
to
remove
soft
tissues
from
the
facial
surface
without
disturbing
the
papillary
tissue
[12].
However,
if
osseous
levels
approximate
the
CEJ,
a
simple
gingivectomy
exposing
the
entire
anatomic
crown
will
be
contraindicated
because
the
biologic
width
of
the
gingival
attachment
can
be
violated.
Therefore,
a
full
thick-
ness
periodontal
flap
with
osteotomy
is
indicated
[13].
When
GS
caused
by
Dentoalveolar
extrusion,
it
can
be
treated
successfully
by
orthodontic
therapy
[14].
While,
a
GS
caused
by
vertical
maxillary
excess,
can
be
treated
by
orthognathic
surgery,
which
is
associated
with
significant
morbidity
and
requires
hospi-
talization
[15].
However,
lip
repositioning
is
recommended
as
an
alternative
treatment
for
GS
which
done
by
removing
a
strip
of
mucosa
from
the
maxillary
labial
vestibule
and
creating
a
partial-
thickness
flap
between
the
mucogingival
junction
and
the
upper
lip
musculature.
Then,
lip
mucosa
sutured
to
the
mucogingival
line,
resulting
in
restriction
the
muscle
pull
and
reduction
of
gingival
display
area
[16].
Lately,
Botulinum
toxin
(BT)
injection
has
been
considered
as
a
minimal
invasive
treatment
of
GS.
It
is
recommended
for
patients
whose
gummy
smiles
are
mainly
caused
by
hyperac-
tive
lip
muscles.
When
injected
BT
intramuscularly,
it
cleaves
the
synaptosome-associated
protein
SNAP-25,
thereby,
blocking
the
release
of
acetylcholine
and
enables
the
repolarization
of
the
post-
synaptic
term
which
produces
partial
chemical
denervation
of
the
muscle,
resulting
in
localized
reduction
in
elevator
muscle
activities
and
relaxes
the
pulling
up
action
of
the
lip
during
smiling
[17].
However,
muscles
of
facial
expression
responsible
for
the
upper
lip
elevation
and
lateral
retraction
upon
smiling
are
Levator
labii
superioris,
Levator
labii
superioris
alaeque
nasii,
Zygomaticus
major,
Zygomaticus
minor
and
Depressor
septii.
All
of
these
mus-
cles
interact
with
the
orbicularis
oris
muscle
in
the
production
of
a
smile
[18].
As
the
injection
of
BT
is
intermuscular,
the
dosage
of
BT
injec-
tion
varies
between
females
and
males,
depend
on
the
lip
muscle
volume.
In
general,
males
have
a
larger
muscle
volume
and
require
more
units
of
BT
to
achieve
the
same
results
as
female
patients
[19].
Moreover,
There
is
an
appropriate
and
effective
point
of
intramus-
cular
BT
injection
where
elevator
lip
muscles
pass
by,
it
is
called
Yonsei
point
[20].
This
point
is
located
at
the
center
of
the
triangle
formed
by
Levator
labii
superioris,
Levator
labii
superioris
alaeque
nasi
and
Zygomaticus
minor.
The
effect
of
BT
is
seen
within
1–2
weeks,
and
usually
lasts
for
4–6
months.
However,
Some
authors
conducted
that
several
injections
of
BT
could
prolong
the
reduction
of
gingival
exposure
[21,22].
One
explanation
of
this
process
is
that
the
prolonged
mus-
cle
paralysis
that
occurs
after
several
injections
can
lately
lead
to
partial
muscle
atrophy
and
permanent
decrease
in
contraction
abil-
ity,
even
after
the
disappearance
of
the
toxic
effect
[23].
It
is
important
not
to
give
injections
before
its
effect
has
com-
pletely
faded
to
avoid
the
formation
of
antibodies
against
the
toxins,
which
can
lead
to
disappointing
results
later
on.
It
is
contraindicated
for
pregnant
or
lactating
women,
neuromuscular
patients,
patients,
those
under
treatment
of
calcium
channel
block-
ers,
cyclosporine
and
aminoglycosides
drugs
and
patients
with
a
history
of
hypersensitivity
to
Botox
toxin
or
saline
solution
[24].
Generally,
the
Botox
treatment
is
safe
when
its
technique
and
quantity
are
administered
properly.
However,
there
are
some
local-
ized
side
effects
which
are
seen
rarely
including;
pain,
infection,
bruising,
inflammation,
edema,
loss
of
muscle
strength,
nerve
palsy,
hematoma.
In
addition,
improper
injection
technique
may
result
in
asymmetrical
appearance
of
a
smile,
some
difficulties
in
speech,
chewing
and/or
drinking.
Over-administration
could
cause
drooping
or
ptosis
of
the
lip
below
the
gingival
margin
causing
obstruction
of
visible
teeth
on
full
smile
[25,26].
Fig.
1.
Sever
gingival
display
during
smiling.
In
this
case,
a
successful
management
of
sever
gummy
smile
using
gingivectomy
surgical
procedures
combined
with
BT
injec-
tions
had
achieved
satisfactory
results
without
the
need
for
an
extensive
surgery.
This
manuscript
has
been
reported
in
accordance
with
the
SCARE
criteria
[27].
2.
Case
presentation
A
24
year
old
female
patient
presented
to
the
periodontal
clin-
ics,
in
our
institution
with
the
chief
complaint
of
excessive
gingival
display
during
smiling
(as
shown
in
Fig.
1)
which
affected
her
con-
fidence
and
physiological
state
and
corresponding
to
that
she
used
to
hide
her
smile
by
her
hands.
The
medical
and
dental
histories
revealed
that
she
was
systemically
and
dentally
healthy
with
unre-
markable
use
of
any
drugs.
However,
she
had
a
positive
family
history
of
gummy
smile
related
to
her
mother.
2.1.
Examination
and
periodontal
evaluation
Clinical
observation
revealed
excessive
anterior
facial
height,
primarily
in
the
lower
third
of
the
face
(the
vertical
facial
propor-
tion
from
the
midface
to
lower
1/3
ratio
of
60/40%),
facial
symmetry,
and
high
smile
(gummy
smile).
Her
upper
lip
when
measured
from
the
sub-nasal
to
the
inferior
border
of
the
upper
lip
was
20
mm,
which
is
considered
to
be
within
normal
limits.
While,
the
incisor
display
at
rest
position
measured
from
upper
lip
to
incisal
edges
of
maxillary
incisors
was
6
mm
(Fig.
2).
On
periodontal
examination,
it
was
observed
that
this
patient
had
maintained
a
relatively
good
oral
hygiene
as
minimal
amounts
of
plaque
and
calculus
deposits
were
recorded.
The
gingiva
was
firm,
pink
and
thick
biotype.
However,
on
initial
probing
depth
measurements
of
maxillary
anterior
teeth,
relatively
2–3
mm
were
measured
by
UNC-15
probe
without
clinical
attachment
loss
or
bleeding.
Also,
the
osseous
crest
was
in
a
normal
relationship
to
the
cementoenamel
junction.
On
spontaneous
smiling,
patient’s
teeth
were
visible
from
maxillary
right
first
premolar
to
maxillary
left
first
premolar.
Also,
11–12
mm
of
vertical
exposure
of
gingiva
was
measured
from
the
inferior
border
of
the
upper
lip
and
gingival
margins
of
maxillary
anterior
teeth.
The
area
of
gingival
exposure
was
measured
1
day
prior
to
gin-
givectomy
procedures,
before
Botox
administration,
5th
and
14th
day
of
Botox
administration.
Thus,
four
recordings
were
done.
Pre-
CASE
REPORT
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International
Journal
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Case
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171
Fig.
2.
The
incisor
display
at
rest
position.
treatment
and
post-
treatment
photographs
were
taken
to
evaluate
the
level
of
improvement.
2.2.
Treatment
considerations
A
diagnosis
of
mixed
gummy
smile
type
(excessive
gum
expo-
sure
in
both
the
anterior
and
posterior
regions)
[24]
was
reached.
The
etiologic
factors
in
this
case
involved;
hypermobility
of
upper
lip,
vertical
maxillary
excess
and
short
clinical
crowns
(type
IA
altered
passive
eruption)
[25,28].
The
patient
was
a
candidate
for
orthognathic
surgery.
But
unwilling
to
go
through
a
complicated
surgical
procedure
involving
hospitalization,
and
yet
hoping
her
smile
fixed.
Hence,
she
was
given
an
option
of
compromised
cor-
rection
by
doing
surgical
crown
lengthening
of
removing
the
soft
tissue
only
(conventional
external
beveled
gingivectomy
on
facial
aspects
of
teeth)
to
increase
the
appearing
crown
followed
by
the
injection
of
Botulinum
toxin
to
relax
the
lip
muscles
during
smiling.
The
patient
was
shown
visual
videos
and
pictures
of
previous
cases
to
explain
exactly
the
steps
of
the
treatment
plan.
Addi-
tionally,
the
patient
was
well
informed
about
all
instructions
and
complications
and
a
written
informed
consent
was
obtained.
2.3.
Treatment
progress
2.3.1.
Surgical
procedures
After
obtaining
the
approval
of
the
treatment
plan
and
informed
consent,
the
phase
I
periodontal
therapy,
including
supragingival
and
subgingival
scaling
was
performed,
and
oral
hygiene
instruc-
tions
were
given
by
postgraduates.
A
week
later,
the
patient
was
ready
to
perform
conventional
gingivectomy.
A
number
of
steps
were
followed
to
achieve
the
perfectly
tai-
lored
gingivectomy,
which
was
done
by
a
professional
periodontist.
Firstly,
An
adequate
dose
of
local
anesthesia
(lignocaine
2%
with
epinephrine
1:100,000)
was
administered
in
the
vestibular
mucosa
from
maxillary
right
first
premolar
to
maxillary
left
first
premolar.
Secondly,
bleeding
points
were
marked
with
the
pocket
marker
and
the
points
were
joined
to
prepare
a
line
of
excision.
After
that,
exter-
nal
bevel
gingivectomy
incisions
were
done
in
the
anterior
region
on
the
facial
surface
only
using
surgical
blade
#15c
(Hu-Friedy)
Fig.
3.
a:
Immediately
after
gingivectomy.
b:
1
week
postoperatively.
c:
2
months
postoperatively.
placed
45angle
to
the
tooth
long
axis,
apically
to
the
bleeding
points.
Then,
the
forceps
with
the
help
of
Orban
knife
removed
the
excised
gingival
segment.
Afterwards,
the
gingiva
was
contoured
and
scraped
to
remove
residual
tissue
tags.
Finally,
a
periodontal
dressing
was
applied
to
gingiva.
The
postoperative
pain
was
managed
with
600
mg
ibuprofen
three
times
daily
for
3
days.
Patient
was
instructed
to
apply
ice
pack
post-operatively
and
avoid
hot
drinks
for
the
first
24
h.
The
periodontal
dressing
was
removed
after
5
days
and
was
advised
to
rinse
gently
with
0.12%
Chlorhexidine
Gluconate
twice
daily
for
2
weeks.
Follow-up
examinations
revealed
exposure
of
the
complete
anatomical
crowns
of
upper
anterior
teeth,
thereby
enhancing
the
esthetic
appearance
of
the
teeth
and
reducing
the
gingival
display.
CASE
REPORT
OPEN
ACCESS
172
D.
Mostafa
/
International
Journal
of
Surgery
Case
Reports
42
(2018)
169–174
Fig.
4.
a:
The
sites
of
injections
of
total
20
units
of
BT.
b:
After
5
days
of
first
visit
of
Botox
injection.
c:
After
14
days
of
20
units
of
Botox
injection.
The
patient
was
recalled
for
re-evaluation.
The
results
are
presented
in
Fig.
3a–c.
2.3.2.
Botox
injection
procedures
Before
injection,
Botulinum
toxin
type-A
was
diluted
to
yield
2
units
per
0.05
ml
by
adding
2.5
ml
0.9%
normal
saline
solution
to
100
units
of
vacuum-dried
Clostridium
Botulinum
toxin
type-
A.
Insulin
syringes
of
1
ml
with
removable
30
gauge
needles
were
used.
The
sites
of
injection
were
determined
by
the
periodontist
by
palpating
the
muscles
during
smiling
and
relaxing
movements
to
ensure
the
accurate
locations
of
injections.
The
sites
were
cleaned
and
sterilized
after
topical
anesthesia
application.
The
injections
were
done
on
2
sites;
the
first
site,
4
units
were
injected
on
each
side
of
the
nasolabial
fold,
1
cm
lateral
and
below
the
nasal
ala
–Yonsei
point
while
on
the
second
site,
2
units
were
injected
on
each
side
of
nasolabial
fold,
at
the
point
of
the
greatest
lateral
contraction
during
the
smile
as
shown
in
Fig.
4a.
The
depth
of
administration
was
intramuscular
with
the
needle
perpendicular
to
the
skin
sur-
face
and
bevel
facing
upwards.
The
patient
was
advised
not
to
lie
down,
do
exercise,
or
massage
the
injected
area
during
the
first
4
h
after
the
procedure.
Five
days
later,
the
patient
was
re-evaluated
as
the
exposed
area
of
gingiva
decreased
5
mm
as
shown
in
Fig.
4b.
She
desired
more
esthetic
smile,
so
another
two
doses
of
Botox
were
injected
to
the
following
sites,
2
units
below
the
nose,
two-thirds
above
the
lip
on
each
the
ridge
of
the
philtrum
(orbicularis
oris
muscle)
and
another
2
units
beside
of
nasolabial
fold,
besides
the
point
of
the
greatest
lateral
contraction
during
the
smile
(Fig.
4a).
2.4.
Treatment
results
After
gingivectomy,
a
rapid
surgical
healing
was
observed.
A
noticed
reduction
of
gingival
display
and
esthetic
improvement
of
her
smile
were
reported.
Pre-injection
gingival
display
was
mea-
sured
by
periodontal
probe
UNC-15
resulting
9–10
mm
relatively.
After
2
months,
a
total
dose
of
20
U
of
BT
was
administered
in
two
visits.
The
patient
was
reviewed
after
two
weeks
and
the
results
showed
a
definite
change
upon
smiling
where
the
gingival
display
decreased
to
1
mm,
which
is
seen
in
Fig.
4c.
Neither
of
redness,
inflammation,
edema,
urticaria,
swelling,
tenderness
was
reported
at
the
sites
of
injection.
Patient
stated
that
she
had
some
difficulty
in
contraction
her
lips
during
kissing.
No
evidence
of
any
other
side
effects
such
as
difficulties
during
smiling
or
talking
or
eating.
Not
only
she
was
truly
satisfied,
but
she
also
recommended
this
treat-
ment
procedure
to
others.
However,
after
11
weeks,
the
gingival
exposed
distance
started
to
increase
1–1.5
mm
returning
back
to
its
post-surgical
appearance
after
6
months.
3.
Discussion
The
potential
etiological
factors
of
GS
can
vary
widely.
In
case
of
altered
passive
eruption,
crown
lengthening
is
the
ideal
treat-
ment,
whether
with
or
without
bone
reduction.
However,
some
cases
are
not
solved
totally
through
crown
lengthening
because
the
amount
of
gingival
display
on
smile
will
not
decrease
significantly
if
the
gummy
smile
is
sever.
Until
recently,
the
correction
of
GS
involves
orthognathic
surgery
or
orthodontic
appliances
especially
for
skeletal
causes.
Now,
the
periodontal
flap
surgeries
have
broad-
ened
in
the
esthetic
rehabilitation.
Rubinstein
and
Kostianovsky
CASE
REPORT
OPEN
ACCESS
D.
Mostafa
/
International
Journal
of
Surgery
Case
Reports
42
(2018)
169–174
173
[29]
described
a
procedure
in
which
an
elliptical
portion
of
gin-
giva
and
buccal
mucosa
is
excised
and
the
approximated
borders
are
sutured
together.
Litton
and
Fournier
[30]
applied
a
treatment
in
which
they
bring
the
lip
down
by
muscle
detachment
from
the
bony
structures
above.
Silva
et
al.
[31]
investigated
the
modified
lip
repositioning
technique
in
patients
with
GS
and
reported
satis-
factory
results.
Nevertheless,
such
surgeries
may
lead
to
frequent
relapse
and
undesirable
side
effects
such
as
scar
contraction
[32].
Lately,
BT
injections
have
progressed
to
be
popular
in
the
cor-
rection
of
the
GS
compared
to
other
surgical
procedures,
it
is
more
preferred
to
patients
because
it
is
less
invasive,
reasonable
cost
and
requires
less
time
despite
its
short-term
effect.
The
purpose
of
the
BT
injectable
technique
is
to
target
and
relax
the
muscles
that
are
excessively
retracted
the
lip
during
smiling
without
causing
any
harm
to
the
nerve
or
the
muscle.
Rubin
et
al.
[33]
stated
that
the
levator
labii
superioris,
the
zygomaticus
minor
and
superior
fibers
of
buccinators
muscles
under
the
nasolabial
fold
are
responsible
for
the
production
of
a
full
smile.
Pessa
[34]
indicated
that
zygo-
maticus
major
and
minor
are
responsible
for
smiling
while
levator
labii
superioris
alaque
nasi
was
responsible
for
the
formation
of
the
medial
portion
of
the
fold
and
minimally
responsible
for
the
ele-
vation
of
upper
lip
and
he
also
found
that
zygomaticus
major
and
minor
are
responsible
for
smiling.
In
this
case
report,
a
young
female
patient
complained
of
exces-
sive
gummy
smile
that
affected
her
psychologically.
The
treatment
was
planned
to
meet
the
desired
outcome
of
the
patient.
First,
a
gingivectomy
procedure
was
done
and
good
results
were
achieved,
including
the
increase
of
the
clinical
crowns
and
decrease
the
gingi-
val
exposed
area,
but
gingivectomy
only
wasn’t
sufficient
to
correct
her
severe
GS
entirely.
Then,
BT
was
injected
with
a
total
dose
of
20
U;
4
units
on
each
side
of
the
nasolabial
fold
(at
the
Yonsei
point),
4
units
on
each
side
of
nasolabial
fold
(divided
into
4
injections)
and
2
units
below
the
nose
(orbicularis
oris
muscle)
as
shown
in
Fig.
4a.
This
approach
was
in
disagreement
with
polo’s
opinion
[35]
as
he
stated
that
the
total
dose
of
BT
injection
should
be
10
U
if
the
gingival
exposure
was
more
than
8.5
mm
and
the
orbicularis
oris
muscle
should
not
be
injected.
But
in
our
case,
results
start
to
be
more
observed
and
effective
after
increasing
the
dose
of
Botox
to
reach
20
U
and
also
after
injection
of
orbicularis
oris.
The
injec-
tions
were
given
in
two
visits
according
to
a
safe
technique
that
was
recommended
by
some
authors
[22,23,36]
who
preferred
to
give
low
doses
of
BT
initially
then
retouching
if
needed
to
avoid
BT
complications.
The
results
were
extremely
significant,
as
the
exposed
gingival
area
became
1
mm,
which
was
very
acceptable.
The
patient
was
very
satisfied
and
pleased
to
achieve
these
results
while
avoiding
the
other
surgical
options.
Previous
studies
[22,37]
had
mentioned
that
the
most
adverse
effects
of
BT
injections
included
a
asym-
metric
smile,
collapse
of
the
oral
commissure
(sad
appearance),
lengthening
of
the
upper
lip
(joker
smile),
inferior
lip
protrusion,
drooling,
and
difficulty
in
smiling,
speaking,
or
eating
which
were
easily
corrected
with
the
retouching
visit.
While
in
this
case,
the
only
reported
side
was
the
difficulty
of
lips
to
contract
strongly.
Some
authors
[21,22,37,38]
stated
that
the
longevity
of
the
BT
effect
on
the
muscles
of
the
lips
was
more
than
12
weeks.
These
outcomes
were
not
in
accordance
with
this
case
results
as
the
effect
of
BT
regressed
in
less
than
3
months.
This
could
be
due
to
the
length
of
gingival
exposure
of
this
case
was
the
longest
in
comparison
with
other
reported
cases
[21,22,37,38,39].
Therefore,
the
duration
of
BT
effectiveness
does
not
related
to
increasing
or
decreasing
the
dose
of
BT
units,
but
depends
on
frequency
of
muscles’
mobility
and
the
length
of
gingival
exposed
during
smiling.
In
addition,
the
results
of
this
case
report
are
not
consistent
with
Chu
et
al.
[10]
who
conducted
that
minor
cosmetic
changes
can
be
done
with
gingivectomy,
injectable
treatment,
or
lip
lowering
procedures
while
correction
of
severe
GS
of
8
mm
or
more
requires
maxillary
bone
shortening
surgery
(orthognathic
surgery)
only.
4.
Conclusion
It
is
important
to
assess
the
patients’
esthetic
expectations
and
show
the
possible
therapeutic
solutions
that
fit
him.
In
this
case,
the
gingivectomy
and
Botox
injections
exhibited
satisfactory
results
for
the
functional
and
esthetic
rehabilitation
of
the
GS
enhanc-
ing
the
patient’s
self-assurance
and
buoyancy.
We
revealed
that
BT
is
considered
as
one
of
the
quickest
alternatives
and
predictable
modalities
for
corrections
of
sever
GS.
Therefore,
Extensive
surgi-
cal
procedures
can
be
avoided
during
treatment
of
GS
by
using
BT
injections.
Mostly,
The
risk
of
complications
of
Botox
injection
depends
on
the
dentist’s
experience
and
the
compliance
of
the
given
post-
operative
advices.
The
dentist
should
have
trained
appropriately
in
Botox
injection
techniques
and
be
aware
of
facial
anatomy.
However,
A
safe
approach
consists
of
administering
low
BT
doses
initially
with
retouching
at
a
later
stage
when
required.
Conflict
of
interest
None.
Funding
Self.
Ethical
approval
Ethical
approval
has
been
obtained
from
Al
Farabi
college
ethical
committee.
The
case
report
is
in
accordance
with
institutional
ethical
guide-
lines.
AEC
07-016.
Consent
Fully
informed
written
consent
was
obtained
from
the
patient.
Authors
contribution
Data
collection,
writing
the
paper,
critical
revision
and
surgical
procedure
was
performed
by
Dr.
Diana
Mostafa.
Guarantor
Dr.
Diana
Mostafa.
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